Treating individuals with schizophrenia requires a broad array of services, including physical health care services, which are primarily financed by Medicaid. Despite high health care costs, most patients do not receive recommended care, and minorities are less likely to do so than whites. Moreover, where patients live matters, with quality and quality disparities varying not just among states but also among counties within states. At a time of reform and fiscal constraint, Medicaid programs are challenged with improving quality and reducing quality disparities among high-needs beneficiaries, including those with schizophrenia, at no extra costs. Factors likely to impact a program?s success include its ability to 1) comprehensively measure quality of care, capturing key domains of both mental health and physical health care, 2) validly and feasibly measure the value of care routinely delivered to their beneficiaries, and importantly, 3) incorporate racial/ethnic disparities in the assessment of value. Such measurement efforts should be undertaken at the level of meaningful geographic units such as counties, where patterns of health care are influenced by policies reflecting both state and local priorities. In response to FOA 16-221, we propose a program of research that seeks to reduce health disparities and improve the health of minority populations served in publicly funded settings through measurement of quality disparities and other critical domains of Medicaid-financed care delivered to adults with schizophrenia living in five diverse states. We will measure quality using evidence- based indicators, and exploiting psychometric principles, we will create an overall composite score as well as key sub-scores. Using the composite measure, we will assess racial/ethnic and geographic disparities in overall quality of care; value, defined as the cost to the Medicaid state program of producing high-quality care; and the cost to the program of eliminating racial/ethnic disparities in quality. We will integrate quality and costs through a unique cost-effectiveness methodology, and to our knowledge, our work will be the first to quantitatively link disparities and costs of serious mental illness care. Our ultimate goal is to provide policymakers with a user-friendly interactive tool to monitor quality, quality disparities, costs, and value, thus enabling evidence-based policymaking.
Aim 1 will assess racial/ethnic and geographic disparities in quality of mental health, physical health, and overall health care routinely delivered to beneficiaries with schizophrenia.
Aim 2 will develop and implement a cost-effectiveness framework to assess value, operationalized as the incremental net monetary benefit of care.
Aim 3 will use the statewide white population as a reference standard to determine the cost of eliminating racial/ethnic quality disparities in each county.
Aim 4 will develop and pilot a user-friendly interactive tool to enable state Medicaid programs to monitor quality, disparities, costs, and value of care. We expect that the proposed research will contribute to the eradication of disparities through advanced performance measurement techniques that will enable routine monitoring of Medicaid care.

Public Health Relevance

The proposed research has high public health relevance because (1) we focus on Medicaid beneficiaries with schizophrenia, a seriously ill population for whom access to high-quality care may be transformative, yet poor quality as well as quality disparities can lead to personal and societal suffering, premature mortality, and high costs, and (2) we seek to substantially expand and develop first evidence on overall quality of care, including physical health care; disparities in quality of care, both racial/ethnic and geographic; value of care, or the cost to the Medicaid state program of producing high-quality care; and the costs of eliminating racial/ethnic disparities in quality. Moreover, through the development of a monitoring tool that will be made available to state Medicaid programs, we will enable evidence-based policy-making aimed at improving care for this vulnerable population.

National Institute of Health (NIH)
National Institute on Minority Health and Health Disparities (NIMHD)
Research Project (R01)
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Special Emphasis Panel (ZRG1)
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Alvidrez, Jennifer L
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Rand Corporation
Santa Monica
United States
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